Palliative Care in the ED: Understand how to integrate Palliative - - PowerPoint PPT Presentation

11/4/2013 1

Palliative Care in the ED:

Don’t Just Do Something…Stand There

Eric Isaacs, MD, FACEP Attending Physician, San Francisco General Hospital and Trauma Center Professor of Emergency Medicine, University of California, San Francisco Eric.Isaacs@emergency.ucsf.edu

Objectives:

Understand how to integrate Palliative Care into the emergency department Differentiate the needs of Palliative Care patients from other ED patients. Discuss the benefits of a Palliative Care approach to selected ED patients.

ACEP: Choosing Wisely Campaign

Don’t delay engaging available palliative and hospice care services in the emergency department for patients likely to benefit. Palliative care provides comfort and relief of symptoms for patients with chronic and/or incurable diseases. Hospice care is palliative care for those patients in the final few months of life. Engage patients chronic or terminal illnesses and their families, in conversations about palliative and hospice services. Early referral from the ED to hospice and palliative care services benefits select patients resulting in both improved quality and quantity of life.

Palliative Care program involving the ED?

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When you hear “Palliative Care in the ED,” do you feel:

1) Nervous? 2) This will be too difficult? 3) I am motivated to incorporate this? 4) All of the above

Tension Points…

Bias towards action The Facts (or the lack thereof) Emotional Issues Communication Issues

Reality Check: Provide Excellent Care

• Triage and disposition
• Right care, right place, in a timely manner
• Optimizing and efficiently using ED

resources

• Reducing ED length of stay
• Increasing ED throughput
• Decreasing ED boarding of admitted patients
• Increasing patient/family satisfaction

Reality Check: Provide Excellent Care

• Triage and disposition
• Right care, right place, in a timely manner
• Optimizing and efficiently using ED

resources

• Reducing ED length of stay
• Increasing ED throughput
• Decreasing ED boarding of admitted patients
• Increasing patient/family satisfaction
• Palliative Care can address all of these!

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Reality Check… Global trajectories

Lunney, Lynn, Foley et al., 2003

1) Sudden death 2) Terminal illness 3) Organ failure 4) Frailty

How Many of you would like to die from:

Lunney, Lynn, Foley et al., 2003

Sudden death (6%) Terminal illness Organ failure Frailty 80% want to die at home 17% die at home. 60% in hospitals and 20% SNF

Global trajectories :

How Many of you would like to die from:

Case # 1: Yellow? Anyone home?

56 year old male with a history of pancreatic cancer Brought in by his wife due to shortness of breath and fatigue He has a chemotherapy appointment on Tuesday and they want to get him tuned up a bit so he can get his next dose of chemo

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Case # 1: Yellow? Anyone home?

Vital Signs: Temp 38.6 (oral), P . 110, BP . 92/48, RR 24 As you walk into the room, Patient is severely jaundiced Abdomen very distended with ascites Looks in mild respiratory distress

There are no beds; it will be 3 hours…

Your Thoughts…? Your Thoughts…?

A-B-C IV-O2-Monitor “WHY did she bring him to the ED?” “Just get him upstairs” “%$#@!! Oncologists” “We have some talking to do…”

Your Thoughts…?

A-B-C IV-O2-Monitor “WHY did she bring him to the ED?” “Just get him upstairs” “%$#@!! Oncologists” “We have some talking to do…”

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Your Thoughts…?

A-B-C IV-O2-Monitor “WHY did she bring him to the ED?” “Just get him upstairs” “%$#@!! Oncologists” “We have some talking to do…”

Palliative Care in the ED

What is Palliative Care?

Intends neither to hasten or postpone death Patient determined goals of care Relief of pain and other distressing symptoms

Includes psychological and spiritual

Involves patients and families Support an understanding of disease process

Models of Palliative Care

Palliative Care consultant comes to the ED Palliative Care consultant will see the patient upstairs

Referred by ED Referred by Hospitalist

No Palliative Care consultant: Emergency Physician responsible for trajectory of care in the hospital. Emergency Physician required to trigger all of these

Palliative Care “Integration” in the Emergency Department

Just like Toxicology… Incorporate palliative care principles into daily practice

Dedicated hospital palliative care team or inpatient palliative care unit NOT REQUIRED

We are doing “Palliative Care” every day

Non-curative symptom management Thinking about trajectories Delivering bad news

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Palliative care

Hospice Benefit

Disease progression Diagnosis of serious illness Death Life prolonging care

Hospice Care

Life prolonging care

Old New

Models of palliative care

Palliative Care in the E.D.: We are missing Patients who need:

Improved communication skills around goals

• f care

More attention on assessment/ documentation of pain and other symptoms Emphasis on symptom interventions with improved EOL outcomes

Palliative Care is like Hypertension…

Routine Follow-up: Do they have a serious or incurable illness?

Printed information Referral for services

Urgency (Would you be surprised if they died in the next 6 months?)

Follow up in one week

Emergency (Would you be surprised if they died during this admission?)

Rapid palliative care assessment ED based palliative care/hospice consult

Who Do We Screen?

Serious or life-threatening illness and one or more: Not Surprised

If the patient died in next 12 months

Bounce-Back

More than one ED visit or admit for same condition in last few months

Uncontrolled Symptoms

ED visit prompted by difficulty to control physical or psychological symptoms

Functional Decline

Decline in function, feeding, weight loss, or caregiver distress

Increasingly Complicated

Long-term care needs requiring more resources or support

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Who to include:

The less obvious but obvious Dialysis Patients Nearly 25% per year Mortality for a 40 year old (8.4 vs. 37 years) COPD (Third leading cause of death in US) CHF (NYH Class 4 – 1 yr mortality=50-66%)

Who to Include: Hospice Eligible (>50% chance dying in next 6 months)

Progressive disease

increased symptoms, worsening lab values or functional status and/or evidence of metastatic disease, particularly brain

Weight loss >5% in last 3 months Karnofsky Performance Scale or PPS< 70%

Palliative performance scale

Percent Activity Ambulatio n Activity Self-Care Intake LOC

Estimated Median Survival (Days) 70 Reduced No job Full Normal

• r

reduced Full 108-145 40 Mainly bed No job No hobbies No housework Occasional Assistance Normal

• r

reduced Full or drowsy 18-41 10 Bed bound No job No hobbies No housework Significant Assistance Mouth care

• nly

Drowsy /coma 1-6

Hospice

Hospice has greatest patient/family satisfaction: Process not a place

Protocol driven medications, equipment, support of physical, psychosocial and spiritual needs.

Some departments can refer directly to hospice

Need a lot of support

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 2011 Center to Advance Palliative Care 29

What if the Intervention Began EARLIER than the ICU?

Early Intervention Associated with Cost Savings

Live Discharges Hospital Deaths Costs Usual Care Palliative Care ∆ Usual Care Palliative Care ∆ Per Day $830 $666 $174* $1,484 $1,110 $374* Per Admission $11,140 $9,445 $1,696** $22,674 $17,765 $4,908** Laboratory $1,227 $803 $424* $2,765 $1,838 $926* ICU $7,096 $1,917 $5,178* $14,542 $7,929 $7,776* Pharmacy $2,190 $2,001 $190 $5,625 $4,081 $1,544*** Imaging $890 $949 ($58)*** $1,673 $1,540 $133 Died in ICU X X X 18% 4% 14%* ED palliative care consult ? ? ? ? ? ? *P<.001 **P<.01 ***P<.05 Morrison RS. Arch Intern Med 2008

Goals of Care/Code Discussion

Who to include?

Gestalt…you are better than you think We are really good at sick or not sick The better you know the patient, the worse you are at predicting prognosis (Too Optimistic)

Plan for the worst…hope for the best

Assessment choice

Patient condition drives assessment

Triage/Bedside Assessment Serious/Terminal Illness Unstable/Critical (e.g. near arrest, VS compromised) Stable Focused Assessment ‘ABCD’ Expanded Assessment ‘NEST’

Advance care plan Make the patient feel Better Caregivers to consider Decision-making capacity Covers physical, psychosocial domains If patient stabilizes, move onto sub-acute assessment

ABCD Assessment

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Case # 1: Yellow? Anyone home?

Triage/Bedside Assessment Serious/Terminal Illness Unstable/Critical (e.g. near arrest, VS compromised) Stable Focused Assessment ‘ABCD’ Expanded Assessment ‘NEST’

Case # 1: Yellow? Anyone home?

Advance Care Plan: No details. No compressions.

Doesn’t believe he can be cured, but wants to squeeze out a bit more time.

Better: Oxygen, Fluid, Antibiotics, consider paracentesis Care givers: “I need you to do everything; I don’t know what I am going to do without him” Decision-Making Capacity: understand and process information, articulate a decision, consistent values

NEST

N: social NEEDS guide post-ED disposition and prevent repeat visits? E: EXISTENTIAL needs: Distress, Settledness, Faith, Wishes, Unfinished business S: SYMPTOMS: (physical or psychological) require treatment during this visit? T: THERAPEUTIC goals be for this ED visit or hospitalization?

Getting the “DNR”

What is a good goals/code discussion?

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What is a good goals/code discussion?

What is a good goals/code discussion?

Patient is expert in own values and goals Our expertise is treatment, procedures and their indications Our job is to match procedures to their values and goals

6 (+1) Goals/Code Discussion Items:

Understanding of your illness Information preferences Fears and worries Goals (if time is short) Trade-offs (to achieve your goals) Unacceptable states Recommend and listen for response

Susan Block & Atul Gawande

11/4/2013 11 6 (+1) Goals/Code Discussion Items: Understanding (U-You) Information (I-I) Fears (F-Feel) Goals (G-Good) Trade-offs (T-Talking) Unacceptable (U-Ultimate) Recommend (R-Responsibility)

Case # 1: Yellow? Anyone home?

Understanding: Terminal; obstructing bile Information: Engineer; likes details Fears: Wife will be lonely and kids last memory. Goals: Make it to Thanksgiving Trade-offs: Painful procedures Unacceptable states: A drain on family and unable to communicate Recommend and listen for response Make a plan…

Principles of Communication

Undivided attention Address patient’s agenda Track emotion and cognitive data Move conversation one step at a time Articulate empathy explicitly Focus on what we CAN do Big picture goals before talking interventions

Tips for Success:

Open ended questions…”Tell me more about that” “How much time do I have?”

“Tell me why you are asking”

If negative emotions, stop & change direction

Goals and Tradeoffs: “What is your unfinished business?”

Don’t be afraid to use words death or dying Pay attention when someone says “Good job” Debrief/Solicit feedback

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Pitfalls

“There is nothing we can do” “Everything is going to be ok” “Should we do everything?” No need for a menu

Conclusion

Integrate PC into your daily practice Many missed patients with unmet needs needing Palliative Care

Do an assessment on those who may die in the next 12 months.

Like Hypertension: Emergency/Urgency/routine

Focus on goals not menu items Communication strategies

Resources:

Fast Facts: www.eperc.mcw.edu/EPERC/FastFactsandConcepts Center to Advance Palliative Care: www.capc.org EPEC-EM: Education in Palliative and End-of-life Care www.epec.net/epec_em.php Opioids App ePrognosis Hospice in a Minute

Questions?

Eric.Isaacs@emergency.ucsf.edu